CATHOLIC MASS MEDIA AWARDS finalist_Good Grief
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[In The Big C Magazine, January-March 2006 Issue,
Finalist in the 2006 Catholic Mass Media Awards]
GOOD GRIEF: from Denial to Courage
By Bobby C. Caingles
Grief. . . . . “deep, mental anguish, as that arising from bereavement (or a sense of being
desolate).”* It’s the idea of a beautiful piece of land flowing in a symphony of
elevations. . . . then of a sudden deluge rushing in from all sides, isolating one mountain
crest and swallowing up all the rest. The person left alone on this island does battle with
this situation in varying degrees of loneliness, anger, hopefulness, hopelessness,
resignation, or feistiness.
Dra. Elizabeth L. Espinosa-Rondain, M.D., FPPA, a consultant at the Makati Medical
Center Psychiatry Section, deals with the management of these overwhelming feelings of
aloneness amidst a traumatic loss among her patients—among these, cancer victims.
Losing Oneself
There is a peculiar aspect to the grief that a patient who has been diagnosed as having
cancer or a terminal illness experiences. “It’s a sense of loss over something closest to
them—their own lives,” explains the established psychiatrist. Another characteristic of
grief in cancer patients is that it is anticipatory. “May taning na ang buhay mo. . . . hindi
abrupt ang death,” Dra. Rondain explains.
This second characteristic could be seen both as a blessing and a curse. In the negative
light, some may loathe the lingering nature of the illness, the pain, and the grief. In the
positive light, Dra. Rondain tends to view this period between the moment of diagnosis
and what could be the demise of a person as a “grace period.” The patient is given
enough time to go through the Grief Process—which is critical to the management of
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his/her illness. How the patient allows himself/herself to experience each specific phase
of Grief can very well determine the quality of life he/she will enjoy.
This Isn’t Real
There are Four Stages of Grief. “Right after someone is diagnosed with cancer, the initial
emotion is Denial and Shock (Stage 1),” she says.
The usual thoughts that come to mind are: “This isn’t real,” “This can’t be happening to
me,” or “Why me???.” “This is the time when [terminal] patients go to other doctors for
2nd, 3rd, or 4th opinions,” the doctor explains. All of this seeks to give life to the hope
that “all this was a big mistake.” Patients look for doctors who will tell them what they
want to hear.
What about those patients who, upon hearing the doctor’s diagnosis, immediately say,
“It’s God’s will” or some other similar expression of resignation to fate. “People like that
have not really processed what’s going on,” she says. “They tend to spiritualize or
rationalize. . . . reality has reached the cognitive part of them, but not the feeling part,”
she explains.
This is Unfair!!!
The Second Stage involves an interplay of Anger and Guilt.
There is now an awareness that “Something’s wrong with me” or that “I am sick.”
Reality is slowly sinking down to the “feeling” level. And once reality hits that level, it
makes quite an impact. Anger and Guilt provide the means of emotional release for the
cancer patient. Anger is hostility at the “terminal situation” vented outwards—towards
the illness, towards family members, towards the doctor, towards everyone else who is
enjoying health. The coal on which this fire feeds is a feeling that “one has lost all
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control”; that one no longer has any say on one’s fate; that there is nothing one can do to
change one’s diagnosis or situation.
Guilt is the inward assault on the self for “not taking care of oneself,” for “smoking too
much,” for “not having a checkup earlier,” for “living an unhealthy lifestyle.” The
patient can also suffer from guilt in the aftermath of his/her lashing out at the people
around her (usually those who love her most) at the time of her battle with cancer [or the
terminal illness].
In the context of one’s bereavement or processing one’s grief, both Anger and Guilt are
neither right nor wrong. “These are coping mechanisms that help the patient to vent their
anxieties,” Dra. Rondain opines. “As long as the manner of expression isn’t a threat to
the patient’s health, wellness, or life—or those of others, these [emotions] are ‘normal’ at
this stage,” she adds.
Maybe. . . .
The 3rd Stage of Grief is Bargaining. It’s when, having accepted the doctor’s
unoptimistic diagnosis, the patient hopes to somehow be able to change the prognosis.
He/she latches her hope on her doctor, some new therapy, breakthrough medicines,
unconventional intervention, and expert surgery. “We still see here some traces of
denial,” Dr. Rondain points out.
It is not uncommon that a patient would try to bargain even with God (“I’ll go to Mass
everyday if I survive this”. . . . “I’ll contribute to charity”. . . . “I’ll be a better husband/
wife”).
The “bargaining” behavior that’s characteristic of this stage is, again, normal. Caregivers
should be aware of this and not try to roughly bring them back to the grimness of reality.
It is the patient, after all, who is undergoing the process of Grieving and he/she
progresses through it at his/her own unique pace.
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At this stage, the patient experiences exaggerated physical symptoms. He / she is pulled
in opposite directions by the reality of physical pain and by a hope that the pain will
somehow go away.
What’s the Point of Living?
Stage 4 of Grief involves Depression. After all the attempts to deny, cope, and bargain,
the patient finally realizes that all these attempts are futile. And he/she may slide into
moments of depression.
Some characteristic symptoms of depression are: 1) loss of sleep or too much sleep; 2)
loss of appetite or too much appetite (for cancer / terminally ill patients, the former is
more common; 3) anxiety (palpitations, chest heaviness, bodily tremors) 4) isolation
(withdrawal from the public or from loved ones); 5) frequent crying; 6) thoughts of
suicide or dying.
Again, to a certain extent, these are “normal” and part of the process of grieving.
“Depression only gets pathological if the patient becomes dysfunctional already—always
angry, can’t work, can’t eat, can’t sleep—for more than two weeks,” Dra. Rondain
explains.
Suicide: Ending Life on One’s Own Terms
In the case of individuals such as Perla Capistrano who had previously attempted suicide,
a little more caution and vigilance is required on the part of the caregiver. “There is a big
probability that someone who has previously attempted suicide will attempt suicide
again,” the doctor admits. The caregiver needs to observe well and perhaps ask probing
questions. “If you see suicidal intentions, if there are suicidal thoughts, attempts to
overdose, or one sees the patient toying with a knife, for instance—then it’s time to seek
professional help,” she advises. Hospitalization, under the care of a psychiatrist would be
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a good course of action. This need not be in a mental care institution but in any hospital
where the patient would be well-monitored.
But if these indicators are absent, then caregivers can just maintain a close watch on the
patient—“laging may kasama dapat,” says Dra. Rondain.
What I Can Do
Dra. Rondain explains that the medical professional-psychiatrist handling a depressive
and terminally ill person should typically just “walk with the patient” in the grieving
process. “I ‘listen’ to the feelings of the patient, affirm her and tell her that what she’s
feeling is ‘normal’ for one who has a terminal illness. Then slowly, I empower her by
helping her make choices—small, basic choices such as what kind of medical treatment
she would like to have, which doctor to consult, what hospital to go to for treatment,” the
doctor says. This helps to restore the patient’s sense of control over her life. The
patient’s oncologist should also do the same by educating both the patient and caregivers
about her situation and the choices that they have. This gives the patient and her family
some sense of control and keeps them from just “resigning themselves” to the inevitable.
What the Caregiver Can Do
“These are also things that caregivers themselves can do. . . . since they usually have a
relationship with the patient, they can sympathize with the patient more and already have
the patient’s trust. The patient might be more willing to reveal their emotions to them,”
says the doctor. On the other hand, she cautions, there are also people who are more
hesitant to reveal their inner struggles to those closest to them. They do not want to
become “added burdens’ and so want their caregivers and family members to think that
they are handling the situation well. In some cases, patients feel more comfortable
opening themselves up to someone who’s a stranger (i.e. a psychiatrist/ counselor).
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What the Patient Can Do
How should a patient manage his/her depression? For many a depressive patient,
depression just kind of “falls on him/her.” It’s something that they seemingly have no
control over. But the patient can take some practical steps to improve his chances of not
falling into a depressive state or of getting out of it. Dra. Rondain advices that patients
should: Express how they feel. This allows them to provide an outlet for the cacophony
of emotions within them. Anger can be one form of release. But there are other
healthier alternatives.
Dra. Rondain suggests that depression-prone patients can maintain and try to capture
their emotions in a personal journal. Their daily documentation of their journey will
help them to somehow look at their emotions from an “external” point of view as they go
over or review what they wrote. They can also study and express the intense heights and
depths of their soul-journey through music, painting, or the art form of their choice. If
there were a good time for one to get into these hobbies, it would be amidst a season of
depression. Some form of sport (for approval of an oncologist) can also be beneficial.
Prescription for Depressed Caregivers
How should a caregiver manage a loved one’s depression? He/she should consciously
and regularly remind himself that the turmoil he sees in the patient/ loved one is
“normal.” It is normal because it is part of the grieving process. Sometimes, the
caregiver may have to himself engage in some form of outlet for his fatigued emotions
and body. In the heat of an altercation with a patient, for instance, it’s alright for a
caregiver to take time out and say, “I can’t take this at the moment. . . . “ or “I need to
go for a while. . . . “ After which he should do something for himself.
The caregiver might himself tether very closely to a depressive state. “It is not
uncommon for caregivers to experience a feeling of being drained,” Dra. Rondain points
out. They feel like they’re the patient’s “punching bag” and that they’re trapped in that
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role. So she also advises caregivers to refresh themselves in some way. Caregivers
oftentimes feel guilty when they want to take time off for themselves. This is wrong.
“(Caregivers) should try to balance their activities,” the doctor explains. “Minsan naiinis
na sya sa pasyente. . . .” she cites. These are telltale signs that the caregiver needs to pay
attention to his/her own emotional welfare. A caregiver should pursue some hobby or
take a break (no matter how short) somehow—watch a movie, go out with friends—
without guilt. “Then when they come back to their loved ones whom they’re taking care
of, mas masaya na sila, di ba?” points out Dra. Rondain.
I Accept This
Finally, Stage 5 is where the patient wants to get to. It’s the point of Acceptance. After
going through the earlier stages, the cancer victim is finally able to say “I accept this.”
At this point, this is no longer just rationalization. He or she is now able to talk about the
illness or the loss. This verbalization of one’s journey is, in itself, a coping mechanism.
Others who have resolved their struggle with their illness, choose to help other cancer
victims who are still in the thick of the fight—either on a personal basis or as part of a
cancer organization. Others dare to go even farther—beyond the circles of cancer
strugglers—and into the wider world of the living. They come to realize that, although
they deal with the very real possibility of death on a daily basis, they are still, after all,
still alive and so choose to interact with others who also enjoy Life. For some, this
resolution provides a never-before experienced zest for life, adventure, and fullness in
relationships.
Courage Born
The Grief Process is not cast in stone. There is no fixed timetable. Each patient
progresses at his or her own pace. The only thing certain is that each will and must pass
through these stages for emotional healing to take place. “A patient may go in and out of
these stages,” explains Dra. Rondain. Or they may even regress and go back to an earlier
stage, she adds.
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As a process, Grief must take its course. It is painful, as most healing treatments are. But
it is actually very helpful and allows the patient to get a grip on his or her delicate,
fleeting world. The alternative is more painful, warns psychiatrists. “If one doesn’t go
through this, he (or she) could end up bitter, complaining, unable to resolve the present
reality,” says Dra. Rondain. And without a grasp of the present, the future remains a
nebulous, scary prospect. Out of all this, a Courage is born which prepares the patient for
either the hoped-for outcome of remission or a no-regrets “moving on” after a Life welllived.
*The American Heritage Dictionary of the English Language, 3 rd Edition.